Cardiovascular Business - May/June 2008 - (Page 19)

Proportion of Patients Achieving D2B time ≤ 90 minutes 100– 90– 80– Percentage of Patients 70– 60– 50– 40– 30– 20– 10– 0– the overall door-to-balloon times by 11 percent. By 2007, our overall median door-to-balloon time was 58 minutes and our off-hour door-to-balloon time was 57 minutes,” Aguirre says. 96 87 75 64 52 42 55 80 65 80 66 79 96 97 2001 2002 2003 2004 Year 2005 2006 2007 Memorial Medical Center exhibited off-hour D2B time improvement after implementing two costless changes: adjusting the on-hour presence of the cath lab team and incorporating the ED nurses into the process. (Source: F. Aguirre) *P value for trend (on-hours): 0.0001 † P value for trend (off-hours): 0.0001 On-Hours* Off-Hours† ECG with the EMS While a pre-activation ECG is a sure-fire method of reducing door-to-balloon times, it is not necessarily the most economical. On average, a preactivation ECG device costs the hospital about $30,000, and between $15,000 and $18,000 to update current equipment. Even more important and challenging is coordinating pre-activation ECG with local emergency medical services (EMS). The two methods adopted by Memorial Medical Center were less challenging and less expensive then initiating a pre-activation ECG, Aguirre says. Ting further breaks down the door-to-balloon process into four time-sensitive areas: ■ Door to ECG time ■ ECG to cath lab activation time ■ Cath lab activation to cath lab arrival time, and ■ Cath lab arrival to balloon time. For example, even if someone else activates the cath lab, the point of activation to the point of actually getting the patient’s artery open off-hours is on average 30 minutes, according to Ting, which is why he felt it necessary to examine the complications involved with each step separately. The main stumbling block to reducing off-hour door-to-balloon times lies in the cath lab activation to cath lab arrival time. Typically, cath lab personnel will arrive within 20 to 30 minutes. Aguirre notes that during on-hours, 36 percent of the time is spent waiting for a cath lab to become available, while during off-hours, 57 percent of the time is spent in the ED, waiting for the cath lab to become activated. Many experts agree, however, that pre-hospital ECG is the best method to reduce off-hour door-to-balloon times. “Theoretically, when the paramedics make a diagnosis with a pre-hospital ECG at first medical contact, the team can be right behind the patient arriving to the hospital,” says Ting. George M. Kichura, MD, a member of the Mercy Health System in St. Louis, Mo., has run into logistical snags trying to initiate a statewide door-to-balloon program. Even with companion bills in the Missouri House and Senate to support a statewide door-toballoon program, the sticking point is finding regional solutions that fit the many EMS companies. What if the patient is closest to a hospital across the state line? Who determines which hospitals to bypass? Who will pay for the 12-lead ECG machines needed in the EMS vehicles? If you can solve these and other problems and enact an on-hours door-to-balloon program, you can then begin to focus on off-hour improvement, Kichura said. He is committed to the project, but worries that others will find the process to initiate a door-to-balloon program too cumbersome and will instead resort to first-line thrombolytic treatment. While there is a role for thrombolytics—not everyone can get optimal door-to-balloon times, for example—the key is to have a system in place, a standardized approach, according to Timothy Henry, MD, an interventional cardiologist at the Minneapolis Heart Institute. Henry’s door-to-balloon area has several zones, depending on the distance from the main hospital, and each zone’s protocol may differ somewhat to accommodate the travel time. The advantage of having a system in place, however, is that it can be adjusted for the slightest changes, such as those needed to improve off-hour door-to-balloon times, Henry said. Once the logistics of organizing the local EMS are ironed out, another challenge is to educate the public to utilize the emergency service, rather than relying on relatives to drive them to the hospital. Paramedics are much more highly trained than in years past and are able to provide important pre-hospital treatment. Ting and his Mayo colleagues have implemented a pre-activation CardiovascularBusiness.com Cardiovascular Business 19 http://CardiovascularBusiness.com

Table of Contents Feed for the Digital Edition of Cardiovascular Business - May/June 2008

Cardiovascular Business - May/June 2008 Contents First Word Cover Story - Coronary CTA: Drafting the Strategic Plan Financing New Technologies: Early Adopters, Lease vs. Purchase, and Joint Ventures Clinical Study Digest: ACE or ARB: It's Your Choice Can Off-Hour D2B Times Be Reduced Without Breaking the Bank? Digital Image Management Primer: Integrating Echo SPECT/CT for Cardiac Disease Detection: An Economic Conundrum Integrating the Healthcare Enterprise Connects IT Systems News & Views Calendar Reader's Resources The Back Page

Cardiovascular Business - May/June 2008

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